title: Hospitalization risks related to vascular access type among incident US hemodialysis patients.
abstract: BACKGROUND
  The excess morbidity and mortality related to catheter utilization at and immediately following dialysis initiation may simply be a proxy for poor prognosis. We examined hospitalization burden related to vascular access (VA) type among incident patients who received some predialysis care.
  
  
  METHODS
  We identified a random sample of incident US Dialysis Outcomes and Practice Patterns Study hemodialysis patients (1996-2004) who reported predialysis nephrologist care. VA utilization was assessed at baseline and throughout the first 6 months on dialysis. Poisson regression was used to estimate the risk of all-cause and cause-specific hospitalizations during the first 6 months.
  
  
  RESULTS
  Among 2635 incident patients, 60% were dialyzing with a catheter, 22% with a graft and 18% with a fistula at baseline. Compared to fistulae, baseline catheter use was associated with an increased risk of all-cause hospitalization [adjusted relative risk (RR) = 1.30, 95% confidence interval (CI): 1.09-1.54] and graft use was not (RR = 1.07, 95% CI: 0.89-1.28). Allowing for VA changes over time, the risk of catheter versus fistula use was more pronounced (RR = 1.72, 95% CI: 1.42-2.08) and increased slightly for graft use (RR = 1.15, 95% CI: 0.94-1.41). Baseline catheter use was most strongly related to infection-related (RR = 1.47, 95% CI: 0.92-2.36) and VA-related hospitalizations (RR = 1.49, 95% CI: 1.06-2.11). These effects were further strengthened when VA use was allowed to vary over time (RR = 2.31, 95% CI: 1.48-3.61 and RR = 3.10, 95% CI: 1.95-4.91, respectively). A similar pattern was noted for VA-related hospitalizations with graft use. Discussion. Among potentially healthier incident patients, hospitalization risk, particularly infection and VA-related, was highest for patients dialyzing with a catheter at initiation and throughout follow-up, providing further support to clinical practice recommendations to minimize catheter placement.
authors.affiliation: Department of Biostatistics and Epidemiology, Amgen Inc, Thousand Oaks, CA, USA.
authors.forename: Leslie J
authors.initials: LJ
authors.lastname: Ng
authors.forename: Fangfei
authors.initials: F
authors.lastname: Chen
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Pisoni
authors.forename: Mahesh
authors.initials: M
authors.lastname: Krishnan
authors.forename: Donna
authors.initials: D
authors.lastname: Mapes
authors.forename: Marcia
authors.initials: M
authors.lastname: Keen
authors.forename: Brian D
authors.initials: BD
authors.lastname: Bradbury
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D002408:Catheters, Indwelling; D017321:Clinical Trials, Phase I as Topic; D017322:Clinical Trials, Phase II as Topic; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006760:Hospitalization; D006801:Humans; D007390:International Agencies; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D006435:Renal Dialysis / Q000295:instrumentation*; D012307:Risk Factors; D015996:Survival Rate; D014481:United States